The psychiatric drug crisis

First-line treatment for high cholesterol is still dietary changes and exercise.

I can't speak for the author of the parent post, but my understanding from his comment is:

He's suggesting the development of software to help people track their mental health, in much the same way people currently track other aspects of their day to day life, such as with a fitbit or mapmyrun. If people could track their mood, medications their taking, when and how frequently they take them, etc, that information would be valuable at both an individual and aggregate level.

"Discontinuation syndrome," AKA withdrawal: http://en.wikipedia.org/wiki/SSRI_discontinuation_syndrome

I'm a big "weird crime" geek and pretty much every single one of them, if you dig deep enough (and quick enough--I've seen news articles "cleaned up" after-the-fact to remove references about medications. Doesn't need to be a conspiracy when we have HIPAA), you find that the perpetrator had either been prescribed new meds/upped dosage in the past week or discontinued suddenly. Also, it's a little bit like a miscarriage--if you talk about it even a little, the private stories come out of the woodwork. Some tragedies, some "holy cow, am I glad I figured out what made me want to buy a gun." What kills me is not knowing how many suicides could have been avoided. And that the word isn't out yet, how many more will we see?

I am seriously a little terrified about a mass shortage of these medications (SSRIs and antipsychotics aren't the only medications that can cause akathisia, delusion, homicidal/suicidal ideation...we've got Larium, ADHD meds, I even just read about a weight loss drug with suicidal ideation as a side effect...banned in Europe but A-OK in the US). How irresponsible if pharmaceutical companies just cut these drugs out without giving their patients a method of safely withdrawing from them... Dig around for withdrawal-induced crimes (especially at the local level; more data there), and you'll see that it's actually murderous. The least they can do is research which genotypes are most susceptible to dangerous side effects (for example, is it possible that people with the MTHFR gene mutation or other characteristics are hit with serious withdrawal symptoms?) to share with prescribing doctors.

> To say that "double-blind prospective trials are nearly non-existent" is very wrong.

You need to read each word and think about it. In a prospective trial, subjects are chosen in advance, they aren't drawn from an existing population of people who have already decided to seek psychological help.

A "double-blind, prospective trial" would have to sign people up from a cross-section of the population who have no interest in, or association with, psychological treatments. Then they would be divided into two groups. One group would receive the drug under test, the other would receive a placebo. And the trial would have to be designed so that the two groups wold not be able to tell to which group they belonged. Unfortunately, about the drugs under test, most of them have side effects, which means the subjects aren't blinded (the placebo group have no problem realizing who they are).

Even will all its defects and shortcomings, what I have just described is unheard of in psychological testing.

> Unless you are referring to very old psychiatric drugs, most of them have gone through such trials.

Absolutely false. The kind of design I am describing is simply unheard of. Most trials are of self-selected psychological treatment clients, and it's not uncommon for the "control group" to be what are euphemistically called "no-treatment controls". Guess what that means -- it means the experimental group is compared to people who are told to go home with no treatment and no sham treatment.

> There was a lot of disagreement about the paper you referenced.

Yes, of course -- and that's the way it should be. But there have been enough similar studies and meta-analyses that the outcome is not in question.

> But you know what? That's the best we have right now.

Different topic.

> There certainly is a strong requirement for efficacy in psychiatric drugs as evidenced by how many have failed to get approved by the FDA.

Most of the drugs that just were proven ineffective were not ever tested for efficacy as psychological drugs, they were prescribed off-label -- they were originally approved for some other purpose.

> The end result is that patients with psychiatric illnesses will end up with fewer treatments options unless this changes.

If the treatments were effective, that would be a shame. But they aren't, so it isn't.

Prospective study was probably not the correct term, since that's an epidemiological study. "Placebo controlled study" is probably a better term. And a placebo controlled study is the best evidence for a medical treatment - doing epidemiological studies to determine medication effectiveness doesn't seem right.

Consider an SSRI study for depression. I want to know if someone who is depressed and takes it does better thank someone who is depressed and doesn't take it, or takes a different drug. I don't care what it does in a healthy population, since they probably won't be taking it. I mean, the effects of SSRIs in healthy individuals is an interesting topic, but not relevant if I'm investigating depression treatments.